Ankle Sprain — What Is It?

An ankle sprain happens when your ankle twists, bends, or is turned in a way that causes increased stress to the tissues that surround and support the ankle joints. The leading predisposition to an ankle injury is a previous ankle injury. A significant percentage of people who have an ankle sprain will develop chronic ankle instability.  The most common ankle sprain is to the lateral (outside) ankle in which the ankle is put into a position of excessive flexion and inversion (the foot falls inward and stretches the outer ligaments too far). The medial (inside) of the ankle can also be injured when the ankle is placed in a position of excessive eversion (turning of the foot outwards). This injury may also happen with excessive dorsiflexion (raising the foot upwards towards the shin).

Parents, coaches, and even medical providers often think that an ankle sprain is not a serious injury. It is often presumed that people who’ve experience an ankle sprain can bounce right back into normal physical activities. Research tells us a different story. People who have suffered an ankle sprain can expect to have reduced strength, decreased mobility, and loss of balance that can be significant months later following the initial ankle injury when the ankle sprain is not addressed appropriately. This is despite no significant pain symptoms.

On the positive side, ankle sprains usually have good outcomes as far as returning to physical activities with the appropriate management.  Successful outcomes are dependent on patient commitment to the recovery process and rehabilitation exercises.

An ankle sprain is typically diagnosed based on the mechanism of injury and patient reports of symptoms. A clinical examination by an athletic trainer, physical therapist, or physician assessing the ankle stability is also commonly performed. X-rays can show some abnormal movement in the ankle when the ankle is placed in different directions. Magnetic resonance imaging or an MRI may be used if there is concern of a more significant or severe injury to the ligaments or joint surface of the ankle.  What’s more, ultrasounds will allow a doctor to look at the ligaments while they are moving your ankle into different positions.

Degrees of Ankle Sprains

Ankle sprains are classified or graded in varying degrees of injury. A grade 1 involves stretching or slight tearing of the ligament with mild tenderness that is present.  You may experience lower levels of pain, but you can still walk with minimal discomfort.  The ankle feels and is stable with a grade 1 injury. 

A grade 2 injury involves a higher level of pain than the grade 1 type. Walking is more painful and difficult, but the ankle still feels fairly stable. There is a more severe but incomplete tear of the tissues damaged in the ankle.  This typically brings about swelling and bruising and tenderness to the touch.  

In a grade 3 injury, there is a complete tear of the affected tissues. With a grade 3 tear you can expect to experience swelling, bruising, and more severe pain with touch.  Walking will also be difficult because of pain and the ankle may/will feel unstable and can give out when trying to take a step, especially when on unstable surfaces.

You might think an ankle sprain involves only the ligaments of the ankle, but there are other areas that can be affected. Joint surfaces may be affected due to increased force on the joint surface as well as the joint surfaces being in an abnormal position. Muscles and the tendons associated with the muscles are also impacted. There are a lot of muscles that cross and support the ankle that are vulnerable to being stretched or injured creating dysfunction. In addition to the muscles that cross the ankle, there is also evidence that shows dysfunctions in other musculature in the leg such as altered activation of the glutes.

Chronic ankle sprains are those that have been present for a period of six weeks or longer.  With a chronic ankle sprain you often continue to experience reoccurrence of pain, swelling, and instability with intermittent periods of the ankle feeling good and otherwise normal.  

Symptoms

The most common symptoms of an ankle sprain are pain and difficulty walking. Loss of ankle mobility and weakness in the ankle and foot are also typical symptoms. A severe ankle sprain can cause a feeling of instability in the ankle while walking.

Common symptoms include:

  • Tenderness when you touch the ankle
  • Swelling
  • Bruising
  • Restricted range of motion
  • Popping sensation or sound at the time of injury
  • Pain during daily or athletic activities

NOTE:  the pain might not feel like enough to stop activity

Pain is present with an ankle injury because the nerves are more sensitive.  The joint hurts and may throb. You’ll experience more pain by pressing on the sore area, by moving the foot in certain directions, or even by walking or standing.

Treatment

Treatment of an ankle sprain will depend on the severity of the injury.  Although self-care measures with pain management may be all you need, a medical evaluation might necessary to reveal how badly you’ve sprained your ankle and to determine the appropriate treatment.

Type of Grade Injury Determines Treatment Regimen

Grade 1 sprains call for a period of protection to help control the pain and to decrease stress on the tissues that are injured. Rehabilitation should start immediately for grade 1 ankle sprains.

Grade 2 ankle sprains also involve a period of protection for the same reasons as a Grade 1 injury.  Grade 2 sprains may require several days of rest and protection prior to starting rehabilitation. Early rehabilitation calls for gradually progressing mobility of the ankle along with controlled balance and strength exercises as you re-educate the muscles and ankle joint to achieve normal range of motion.

A Grade 3 ankle sprain requires a longer period of protection in order to control the pain and decrease the stress on the injured tissues. Because of the extent of the injury, Grade 3 sprains usually call for more significant bracing, casting, or boots. This more severe ankle injury may need to be evaluated to determine if surgery is necessary.  The surgery option can be determined by knowing the extent of the injury and checking pain and stability as the ankle heals.

For all grades of injury, following the period of protection of the ankle area, restoring range of motion, strength, and flexibility are important for a return to normal activities.

Early Stages of Rehabilitation

During the early stages of rehabilitation for an ankle sprain, weight bearing can be painful and limit physical activity. Appropriate physical activities may include non-weight bearing mobility and isometric exercises. Progression to weight bearing and proprioceptive functional strength training can occur when the pain levels decrease and the activities are more tolerable.  

Other viable options for maintaining activity during this time of rehab can also include using a pool or modified training equipment such as anti-gravity treadmills.

Once you get the go-ahead to do weight-bearing exercises, it’s recommended that you follow a regimen of continued progression of range-of-motion activities along with neuromuscular and balance exercises. Neuromuscular exercise has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature. In short, neuromuscular exercise addresses the quality of movement and emphasizes joint control.

As the weight bearing and functional activities progress, it is important to monitor and
re-learn correct mechanics and posture. This includes exercises like walking, squatting, jogging, running, and jumping.

After the appropriate healing stages have passed, activities can then progress to faster and higher impact movements. This is predicated on the ability to perform activities without pain, swelling, or limping. When these controlled activities are performed without the aforementioned symptoms, controlled play can be performed. Regular activity resumes when controlled play is completed without pain, swelling, or discomfort of any kind surrounding the ankle.

Keys to a Successful Rehabilitation

Improving postural stability and balance are vital when it comes to returning to normal activities. It is necessary to improve proprioception, as proprioception is very important to the brain as it plays a big role in self-regulation, coordination, posture, body awareness, and the ability to attend and focus.  The proprioceptive system is located in our muscles and joints. It provides us with a sense of body awareness and detects and controls force and pressure.

Being able to return to normal activities is dependent on the amount of dysfunction there is. Studies have shown that clinical and subjective ankle instability can continue for as long as one year after the injury.  Ligament healing occurs typically after six weeks to three months.

A word of caution:  all activities that are weight bearing go through the ankle. So it is important to adhere to a consistent rehabilitation regimen until fully healed.

When to Seek Medical Care

In most cases, an ankle sprain does not call for a trip to the doctor. In the following scenarios you should contact your doctor:

  • Your pain is severe or uncontrolled, in spite of pain control measures, compression, and ice.
  • You cannot walk or cannot walk without severe pain.
  • Your ankle feels unstable when you walk.
  • Your ankle fails to improve within five to seven days.  The pain doesn’t need to be gone, but it should be decreasing.


Sometimes foot and/or ankle fractures occur simultaneously when spraining an ankle. The following symptoms suggest you might have a fracture, may need to limit weight bearing, and need to seek medical attention to evaluate your injury:

  1. Severe or uncontrolled pain
  2. Foot or ankle is misshapen or extremely swollen
  3. Cannot walk or cannot walk without severe pain in the foot and ankle
  4. Severe pain when pressing over the medial or lateral malleolus — the bony bumps on each side of your ankle

Risk Factors and How to Address Them

The most significant risk factor for an ankle sprain is a previous ankle sprain.  Make sure you correctly rehabilitate the ankle after a previous injury.

With that being said, there are other numerous situations that can put you at risk for sustaining an ankle sprain. One of the most common activities that can injure the ankle is walking on poor surfaces such as holes in the ground, over rocks or other uneven surfaces. Do your best to be aware of and improve if possible areas that may cause more potential for injury.

Another potential risk is using poor footwear, changing your shoes or using poor equipment when exercising. Making sure to have the best equipment that you possibly can and gradually transitioning when changing footwear or other equipment can decrease potential for ankle injury. Bracing or taping can be used to help decrease the potential risk for an ankle injury when working on or around unstable surfaces.

Poor nutrition and lack of hydration can put you at risk of an injury. This is easily avoided by maintaining a healthy diet and appropriate hydration seeking professional help when appropriate.

If you’re not using proper technique or body mechanics while participating in activity, this can increase your potential for an ankle injury. Spend time to learn and focus on good body mechanics seeking professional help when needed.

Participating in a lot of sports activities can put you at risk for spraining your ankle as well. Studies reveal that as many as half of ankle injuries occur during athletic activities. This risk factor can be prevented by properly preparing yourself in areas such as strength, balance, agility, and sports skill.

If you have a lack of joint coordination or poor balance and postural control, you are susceptible to an ankle sprain. You can address this by making sure to engage in warm-up activities before rigorous exercises.  These could include stretching movements and other movement prep activities.

Focus should also be placed on ankle and foot strengthening as a part of a balanced exercise and training program.